Archives of Medical Research 36 (2005) 689–696

REVIEW ARTICLE
Global Warming and Infectious Disease
Atul A. Khasnis and Mary D. Nettleman
Department of Medicine, Michigan State University, East Lansing, Michigan
Received for publication March 29, 2005; accepted April 1, 2005 (ARCMED-D-05-00117).

Global warming has serious implications for all aspects of human life, including infectious
diseases. The effect of global warming depends on the complex interaction between the
human host population and the causative infectious agent. From the human standpoint,
changes in the environment may trigger human migration, causing disease patterns to
shift. Crop failures and famine may reduce host resistance to infections. Disease
transmission may be enhanced through the scarcity and contamination of potable water
sources. Importantly, significant economic and political stresses may damage the existing
public health infrastructure, leaving mankind poorly prepared for unexpected epidemics.
Global warming will certainly affect the abundance and distribution of disease vectors.
Altitudes that are currently too cool to sustain vectors will become more conducive to
them. Some vector populations may expand into new geographic areas, whereas others
may disappear. Malaria, dengue, plague, and viruses causing encephalitic syndromes are
among the many vector-borne diseases likely to be affected. Some models suggest that
vector-borne diseases will become more common as the earth warms, although caution
is needed in interpreting these predictions. Clearly, global warming will cause changes
in the epidemiology of infectious diseases. The ability of mankind to react or adapt
is dependent upon the magnitude and speed of the change. The outcome will also depend on
our ability to recognize epidemics early, to contain them effectively, to provide appropriate
treatment, and to commit resources to prevention and research. 쑖 2005 IMSS. Published
by Elsevier Inc.
Key Words: Global warming, Infectious diseases, Climate.

“In nature there are neither rewards nor punishments;
there are only consequences”
—Robert Green Ingersoll
Introduction
The Swedish chemist, Svante Arrhenius, first predicted
global warming in 1896 (1). Since then, it has been a hotly
debated topic among scientists, politicians and environmen-
tal experts alike. Global warming is a gradual process that
threatens to have serious consequences over time, including
elevated sea levels, crop failure and famine, changes in
Address reprint requests to: Mary D. Nettleman, M.D., Department of
Medicine, Michigan State University, Tower B, B427 Clinical CTR, East
Lansing, MI 48824-1313. Phone: ⫹5170 432-9124; E-mail: nettlem2@
msu.edu
global rainfall patterns, changes to plant and animal popula-
tions, and serious health effects. Infectious diseases are
global entities that depend dynamically on the interaction
between the population and the existing regional climate.
Thus, global warming may result in a considerable shift of
the spectrum of infectious diseases. This review will intro-
duce the basic concepts of global warming, focus on the
presently available literature regarding the impact of climatic
changes on human health and infectious disease, and present
a possible picture of the things to come. The available litera-
ture about the future of global warming is a compendium
of intelligent and logical guesswork based on experience
with previous climatic trends and mathematical models of
future climatic change. Lastly, some experts believe that
global warming is not as malevolent as it is commonly
thought to be and might actually have beneficial aspects.
This viewpoint will also be explored in the course of the
review.

0188-4409/05 $–see front matter. Copyright 쑖 2005 IMSS. Published by Elsevier Inc.
d o i : 1 0 .1 0 16 / j . a rc m e d .2 00 5 .0 3 .0 41
690 Khasnis and Nettleman / Archives of Medical Research 36 (2005) 689–696
Global Warming—The Concept and Consequences
The concept of global warming requires a basic understand-
ing of the greenhouse effect. Solar radiation passes through
the atmosphere and is absorbed at the Earth’s surface. This
heat is lost from the earth’s surface as infra-red radiation.
The infra-red radiation cannot escape the atmosphere as
easily as the solar radiation enters. Some of it is trapped
by a number of gases which act similar to the glass in a
greenhouse—heat can enter but cannot exit—resulting in
the Greenhouse Effect. The mathematician and scientist,
Jean Baptiste Fourier, first coined the term greenhouse
effect in 1827 (2). In nature, the greenhouse effect is responsi-
ble for elevating the Earth’s temperature, making it possible
for life to thrive.
Greenhouse gases (3) include carbon dioxide, methane,
nitrous oxide, hydrocarbons, perfluorocarbons and sulfur
hexafluoride. Carbon dioxide, methane and nitrous oxide are
naturally occurring, whereas hydrocarbons (hydrofluoro-
carbons (HFCs), perfluorocarbons (PFCs), and sulfur hexa-
fluoride (SF6) and their derivatives are generated artificially.
HFCs and PFCs are the most heat absorbent. Methane
and nitrous oxide absorb more heat per molecule than carbon
dioxide. Nature’s defense against many of these greenhouse
gases is a sink, which is a reservoir that takes up a chemical
product from another part of the cycle. Soil and trees act as
natural sinks absorbing hundreds of billions of tons of carbon
in the form of CO2 (3). Needless to say, activities such
as uncontrolled deforestation enhance global warming and
could ultimately court an environmental disaster.
Population size and global warming are related because
human activities increase production of greenhouse gases.
This effect culminates in global warming. The observed rise
in global temperature over the 20th century was 0.3⬚ to 0.6⬚C
and this rise is predicted to accelerate (4). The warmest
years in descending order were 1987, 1988, 1983, and
1980 (5).
To explore long-term trends in global temperatures,
Easterling et al. (6) analyzed monthly averaged maximum
and minimum temperatures and the DTR (diurnal tempera-
ture range) at 5400 observing stations around the world. Each
time series from each station was subjected independently to
homogeneity analyses and adjustments according to recently
developed techniques. The observed trend for maximum
temperature was an increase of ⫹0.82⬚C per 100 years, for
minimum temperature was an increase of ⫹1.79⬚C per 100
years; the DTR trend was an increase of ⫺0.79⬚C per
100 years. They explained the positive and negative DTR
trends as having resulted from daily minimum temperature
increasing at a faster rate and decreasing at a slower rate than
the daily maximum temperature, respectively. Jones et al.
(7) also examined rural-station temperature data for Euro-
pean parts of the Soviet Union, eastern Australia and eastern
China and reported similar observations.
According to the U.S. Environmental Protection Agency
(EPA), the sea level has risen 6–8 in. globally and worldwide
precipitation has increased by about 1% during the past
century. The EPA also noted a 5–10% increase in precipita-
tion over the U.S. and a 10–15% increase in rainfall over the
northern tier states and southern Canada over the last century.
The main domain of this precipitation increase was eastern
Canada and the adjacent northern regions of the U.S. (8).
Increasing concentrations of greenhouse gases are likely to
accelerate the rate of this potentially detrimental climate
change.
Rising temperatures are likely to continue. It is predicted
that the average global surface temperature could rise
0.6–2.5⬚C in the next 50 years, and 1.4⬚ to 5.8⬚C by the year
2100 (9). The effect on precipitation and soil moisture is un-
certain. Initially, evaporation will likely increase, resulting
in increased average global precipitation. However, the dis-
tribution of rainfall may become more erratic, leading to
focal areas of flood and drought. If increases in temperature
are sustained, it is also possible that soil moisture may
be permanently lost from some areas. Some experts from
Stanford University have challenged this prediction as they
observed an increase in soil moisture under conditions of
increased temperature (10). They hypothesize that the in-
creased temperature results in early death of plants such as
grasses and wildflowers, thus reducing the surface area for
evaporation. This reduced evaporation results in increased
soil moisture. Frozen soil moisture has also been used to
estimate the growing season in forests and estimating their
efficiency as carbon sinks. Sea levels are predicted to rise
2 ft along most of the U.S. coast.
Impact of Climate on Public Health
It is impossible to quantify the exact risk posed by climate
change. With particular reference to infectious diseases,
the impact depends on the complex interaction between the
human host population and the causative infectious agent.
Important human factors include crowding, food scarcity,
poverty, and local environmental decline. Some health ef-
fects of climate change may result from indirect impacts on
natural ecosystems. For example, altered climatic conditions
can change the habitats of vectors such as mosquitoes or
rats and affect the parasites they carry. Changing the abun-
dance and geographic range of carriers and parasites could
shift the seasonal occurrence of many infectious diseases
and cause them to spread.
The effect of global warming depends heavily on the
ability of humans and public health systems to adapt. Human
migration and economic stresses from climate variability
could threaten human settlement and seriously overwhelm
the public health infrastructure. This scenario might be
worsened further by malnutrition due to crop failure. Facing
this complex threat makes interdisciplinary cooperation
among health professionals, climatologists, environmental
biologists and social scientists imperative to understand and
 Global Warming 691

effectively manage this threat that could result from
global warming.
Renewed understanding of linkages between public
health and global life-support systems is emerging in the
literature (11). New collaborative efforts can confront these
tough challenges through advances in preventive medicine.
In much of the world, the current increasing life expectancy
is likely to be blunted by increased difficulty in accessing
basic requirements such as sanitation and potable water. The
direct and indirect impacts of climate change on human
health have a considerable toll on life, resources (natural and
financial) and working manpower. Altered environmental
influences would also mean courting environmental disasters
such as famines and floods. It known that non-vector-borne
infectious diseases—such as salmonellosis, cholera, and gi-
ardiasis—can thrive under these circumstances (12). Thus,
the impact of climate change depends on several factors. Al-
though exact predictions are impossible, there are significant
areas of concern throughout the world (Table 1) (13).
Water
Water is a basic necessity and its availability is of paramount
importance. Currently, 1.1 billion people do not have access
to adequate supplies of safe water (14), and 2.4 billion people
do not have access to adequate sanitation (15). Adjusting
to new shortages and/or implementing measures to ensure
supply under global warming will impose a heavy burden
on the already stressed national exchequer of developing
countries. Various approaches to reduce the potential scarcity
of water systems as a result of climate change include poli-
cies to eliminate profiteering, efficient management of avail-
able water, improved technology, integrated agriculture
policies, and urban planning and management. At the na-
tional and regional level, integrated water resource manage-
ment should be prioritized. It is also important that the quality
of conserved water be maintained.
Water is a core substance used for cooking, dissolution
and plain consumption. The infectious disease consequences
of contaminated water can be significant. Childhood diarrhea
is already a major cause of premature mortality around the
globe (16). Epidemics of cholera, typhoid, and similar dis-
eases can be expected if the quality of water deteriorates. It
is interesting to note, however, that effective water purifica-
tion and storage attempts at the household level are superior to
attempts at decontaminating water at its source. Gundry
et al. (17) reviewed observational studies investigating this
relationship, as well as studies of home water treatment and
storage interventions. For cholera, a clear relationship was

Table 1. Major potential health impact of global warming

Continent Major potential health impact

Africa Reduced arable land and increase in extreme weather leading to malnutrition and overcrowding
Increase in vector-borne disease, especially malaria with potential increase childhood mortality
Increase in water-borne diseases, with potential increase in childhood mortality from diarrhea
Diversion of limited health resources to cope with new stresses with resulting decreased attention paid to existing diseases
such as HIV
Arctic and polar areas Indigenous peoples lose traditional sources of food as migration patterns change and ice retreats
Loss of polar ice affects global coastlines
Cooling of currents that now maintain temperate climates in Europe and North America
Australasia Increased heat-stress mortality
Increase in selected vector-borne diseases such as dengue and malaria
Loss of coastline and fishing sources
Increase in water-borne diseases, especially in impoverished areas
Reduced air quality resulting in respiratory diseases
Europe Increased heat-stress mortality
Reduced air quality resulting in respiratory diseases
Potential expansion of vector-borne diseases such as encephalitis
Small Island States Potential to introduce/expand cholera, dengue
Loss of coastal land
Changes in fish populations resulting in malnutrition
Latin America Potential increase in vector-borne diseases, including Chagas’ disease and malaria
Potential expansion of water-borne diseases including cholera
Increase in air pollution and high concentrations of ground level ozone resulting in respiratory diseases
North America Increased biting season for vectors and associated increase risk of vector-borne diseases such as encephalitis
Reduced air quality and increased respiratory diseases
Loss of coastline, increased extreme weather events resulting in diversion of economic resources away from existing public
health efforts
Temperate Asia Potential expansion of vector habitat including malaria-bearing mosquitoes and schistosome-spreading snails
Increase in water-borne diseases, especially in impoverished areas
Reduced air quality increasing respiratory diseases
692 Khasnis and Nettleman / Archives of Medical Research 36 (2005) 689–696

found with contaminated water. Home water treatment and reduce arable land (due to increasing sea levels) as well
storage interventions were also found to reduce cholera. For as making presently available land more hostile to crop
general diarrhea, no clear relationship was found with point- cultivation. In the face of a growing population, this would
of-use water quality, although interventions significantly re- amount to lesser availability of food and under-nutrition.
duced the incidence of diarrhea. However, they emphasized Climate change could also affect food production, with
the simultaneous need for improved public education about concentrated decline in low-latitude regions where food
water sanitation. Esrey et al. (18) reviewed 144 water and insecurity often already exists, including Africa, the Middle
sanitation interventions conducted in various developing East and India (23,24). Estimates of hunger risk based on
countries and in the U.S. to look at the effect improved water assumptions about future population growth, international
supply and sanitation facilities had on ascariasis, diarrhea, trade and agricultural technology have not yet factored in
dracunculiasis, hookworm infection, schistosomiasis, and extreme weather events (24) or increases in agricultural pests
trachoma. They showed that improved water supply and san- and pathogens (25).
itation result in substantial reductions in morbidity from
diarrhea (26%), ascariasis (29%), guinea worm infection
(78%), schistosomiasis (77%), trachoma (27%) and a Human Migration
median reduction of 65% in diarrhea-specific mortality and
Through its adverse effect on the environment, population
55% in general child mortality. They recommended that
growth is a significant cause of the increase in the number
nearby water supply and hygienic practices be integrated
of environmental refugees. The United Nations estimates
into water supply and health programs.
that as a result of continuing migration, 65% of the world
population, including 61% of the population in developing
Food regions, will live in cities by the year 2025 (26). As cities
grow, other environments shrink. This problem will be
Currently, 800 million people are malnourished (19). As the
greatly inflated if global warming causes sea levels to
world’s population increases, food consumption is expected
rise, encroaching on vast areas of land. Population shifts
to double over the next few decades. Increased demands for
could occur within a country, or as international or interconti-
food have indirectly exacerbated global warming risks. Prob-
nental fluxes. Such mass movements can potentially impede
lems associated with intensifying production on land already
attempts to achieve stable human development. Unexpected
in use are becoming increasingly evident (20). Expanding
human migration can stress unprepared health infrastructure
the amount of cultivable land is an option for increasing total
especially in the face of a new illness native to the migrant
crop production but could lead to increased competition for
population. Human migration has been a major source of
land, strain on natural resources, increased greenhouse gases,
epidemics throughout history resulting in spread of many
and reduced natural sinks of carbon as a result of ensuing
diseases such as plague and smallpox.
deforestation.
Acute inhabitation disturbances lead to temporary living
The main direct effects of global warming will be through
arrangements such as refugee camps and shelters, which
changes in temperature, precipitation, length of growing
provide ideal grounds for the emergence and spread of infec-
season, and timing of extreme or critical events relative to
tions. The common factors inevitably surrounding temporary
crop development, as well as through changes in atmospheric
living arrangements are crowding, inadequate sanitation,
CO2 concentration (which may have a beneficial effect on
limited access to medical care, deficient clean water and
the growth of many crop types) (21,22). Middle to high
food, mixed strata population and inadequate and ineffective
latitudes may experience increased productivity, whereas the
barriers from vectors and animals (27). Complex ecological
tropics and subtropics are likely to face decline in yields.
interactions result from several factors working in unison
The livelihoods of farmers and pastoral peoples, who make
or in tandem. Rural to urban migration can inject localized
up a large portion of rural populations in some regions, could
infection into a large vulnerable host population. Such health
be negatively affected. Regionally decreased rainfall is likely
perturbations can be the last straw for the health infrastruc-
to compromise agricultural production significantly. Adapta-
ture in overcrowded and rapidly growing cities, leading to a
tion options include changes in crops and crop varieties,
serious breakdown in public health measures and facilitating
biotechnically or genetically developed new crop varie-
establishment of newly introduced infections (28).
ties, changes in planting and reaping schedules, and im-
proved water and irrigation systems availability and
development. Other factors influencing the vulnerability of
Vector-Borne Diseases
agricultural production are per capita income, the fraction
of economy that is dependent on agriculture and preexisting Global climate change will affect disease vectors, which in
land conditions. turn may alter the current patterns of vector-borne diseases
Malnutrition is an important vulnerability factor for infec- (29). The most common vectors, arthropods, are cold-
tious disease. As stated above, global warming is predicted to blooded, meaning that their internal temperature is greatly
 Global Warming
Table 2. Factors affecting arthropod-borne diseases
Vector factors
Size of vector population
Proportion of vectors carrying disease
Biting rate
Availability/requirement for intermediate host
Ability of vector to survive the disease
Lifespan/mortality rate of the vector
Efficiency of transmission of the disease via the arthropod bite
Sustainability and renewal of infected vector population
affected by the temperature of their environment. The inci-
dence of arthropod-borne diseases will depend on both
vector and host factors (Table 2) (28). Climate may affect all
of these factors to some extent but will have its most direct
effect on the size of the vector population. Malaria, dengue,
plague, and viruses causing encephalitic syndromes are
among the many vector-borne diseases that may be affected.
The effect of global warming on malaria has been actively
debated. In modern times, we tend to think of malaria as
a tropical disease. However, malaria has existed in many
temperate areas of the world (30). Outbreaks have occurred as
far north as the Arctic Circle and the disease has flourished
in much of Europe and North America. European visitors
to the New World found malaria already firmly established.
In Europe, cases of malaria persisted throughout the Little Ice
Age, a period of intensely cold winters and cool summers
that began in 1564 (30). The mosquito vectors that carried the
parasite in these temperate climates still exist. Yet, malaria
has almost vanished from developed countries. Clearly, the
reason for the dramatic decrease in cases of malaria is not
climatologic. Rather, the change is attributed to better mos-
quito control measures, and more effective antimalarials. Un-
fortunately, mosquitoes have become alarmingly resistant to
control measures and drug-resistant malaria is spreading.
Malaria cases have been on the rise (31). We cannot rely
on the measure of the past to provide a safe haven for us
in the future. Moreover, the lack of malaria in developed
countries is sustained in part by the lack of infected human
hosts. Mosquitoes rarely encounter an infected host and so
rarely acquire the parasite. Will global warming reverse
these trends?
The situation and the risk are most dire in developing
countries. Malaria is currently concentrated in areas of pov-
erty (32), with 90% of cases occurring in Africa. (33). Ap-
proximately 40% of the world’s population lives in a
malarious area (34). In Africa, there are 300–500 million
cases of malaria annually, with 1.5–2.7 million deaths (33).
Up to 90% of the African deaths occur in children under
the age of 5 years. In contrast, about 1500 cases of malaria
occur each year in the U.S., almost all of which are imported,
with 0 to 12 deaths per year (35).
In many ways, our current inability to control malaria
is a reflection of the uneven distribution of global public
693
Host factors
Size of host population
Susceptibility of existing hosts
Migration/creation of new susceptible hosts
Degree to which the host enters the vector environment
Mortality rate caused by the disease
Potential for prolonged immunity
Availability/efficacy of vector control measures
Availability of disease control measures
health resources. Control of malaria includes vector manage-
ment and disease therapy. Vectors can be reduced through
the use of insecticides that are applied to individuals or their
environment. History has shown that mosquitoes can become
tolerant to potent environmental insecticides and that
some products will have unforeseen consequences for other
wildlife. Personal measures may also be taken including
using insect repellants, room sprays, and screens on win-
dows. Impregnated bed netting has been shown to be an ef-
fective means of reducing malarial transmission. For the poor,
especially in developing countries, the cost of these personal
protective measures is often prohibitive (36).
Malaria control is extremely difficult. The oldest method
of vector control—drainage—still remains the most cost
effective particularly in areas with high population and low
water resources (37). There are studies to show that simple
measures such as irrigation control can control malaria
spread (38,39). The progression of aquatic stages of develop-
ment of the Anopheline vector is accelerated under condi-
tions of increased temperature with optimal larval
development at 28⬚C and optimal adult development be-
tween 28⬚ and 32⬚C (40) Thus, global warming provides
conditions conducive to the spread of malaria.
Malaria transmission is influenced by climate. Clearly,
transmission does not occur in climates where mosquitoes
cannot survive. Warm, moist climates are most conducive
to mosquito propagation and survival. The breeding habitat
of the Anopheles vector is water. Anopheles mosquitoes are
found most commonly in deciduous and mixed forests as
well as around human habitation (41). Mosquito larvae are
found in small pools of water. Factors affecting larval breed-
ing include quantity of food, density of larvae and salinity
of the surrounding medium (42). The eggs are laid singly on
the water surface film and can survive winter weather resil-
iently. The progression of aquatic stages of development
of the Anopheline vector is accelerated under conditions of
increased temperature with optimal larval development at
28⬚C and optimal adult development between 28⬚ and 32⬚C
(40). Malaria transmission cannot occur below 16⬚C or above
33⬚C as sporogony cannot occur. The ideal conditions for
transmission are high humidity and environmental tempera-
tures between 20⬚ and 30⬚C. Rates of transmission also
depend on the number of times the infected mosquito bites
694 Khasnis and Nettleman / Archives of Medical Research 36 (2005) 689–696
the host and the duration of the mosquito lifespan, both of
which are influenced by temperature (37). Thus, global
warming provides conditions conducive to the spread of
malaria.
In holoendemic or hyperendemic areas, childhood mortal-
ity from malaria is high. Over time, the population develops
premunition immunity that allows parasite inhabitation but
protects against infection. This is not the case where malaria
occurs seasonally, implying that spread of malaria to non-
endemic or unexposed regions of the world as a consequence
of climatic change can have severe impact on the vulnera-
ble population. Human migration will also bring infected
persons into contact with uninfected mosquitoes and subse-
quently will expose non-immune hosts to newly infected
mosquitoes.
Deforestation, human migration and agricultural practices
have a serious impact on malarial transmission. Urban ma-
laria has become an increasing health concern in many coun-
tries (41). Crowding of humans in dwellings is associated
with increased indoor mosquito concentrations (43).
Humans, after all, are a source of food for mosquitoes.
Many global warming scenarios include an increase in
the frequency and intensity of the El Niño phenomenon (44).
The El Niño Southern Oscillation is heralded by warm water
flowing off the coast of Peru and Ecuador. It is caused in
part by pressure differences in the air over the Pacific
Ocean. Although beginning in the Pacific, the climatic effects
of El Niño are global. Storms, heavy rain, regional drought,
and warm temperatures are more frequent during El Niño
(45). El Niño seasons have been associated with outbreaks
of malaria in many areas (46,47). However, the association
is not constant and outbreaks have been regionally limited.
It is important to point out that El Niño is a short-term
climate change and that global warming implies a prolonged
change. Thus, it is hazardous to extrapolate the effects of
El Niño to predict the overall results of global climate change
(48). However, El Niño events are predicted to become
more common and more severe with global warming, and
it appears likely that this will facilitate local epidemics of
malaria.
From the standpoint of malaria, the effect of global warm-
ing will be felt most in areas that are currently on the edges
of the range of infected mosquitoes (49). For example, ma-
laria has been shown to march up mountains in response to
wetter, warmer weather (50,51). Altitudes that were once
safe from mosquitoes will be at risk for epidemics. Tanser
and colleagues (33) developed a model to predict the effect
of global warming on exposure to the mosquito vector for
malaria in Africa. The model was based on the historical
associate of rainfall and temperature readings from 1920 to
1980 in Africa. Population estimates were overlaid on top
of regional temperatures and were assumed to remain con-
stant. The model was validated using existing mosquito sur-
veys. Three potential global warming scenarios were
considered, based on estimates from the Intergovernmental
Panel for Climate Change. In the scenarios, atmospheric
carbon dioxide increased by 47, 98, and 126% by the year
2100. Using these estimates, the number of person-months
of exposure to the mosquito vector increased by 16, 23,
and 28% for each scenario, respectively. The increase was
predominately attributable to vector exposure at higher alti-
tudes than currently. Ethiopia, Zimbabwe and South Africa
experienced the largest projected changes. There was little
latitudinal spread into new territories.
Increasing precipitation is not always favorable for mos-
quitoes. Torrential rains may wash away breeding sites and
drought may eliminate the small pools of water favored by
the mosquitoes for their eggs. On the other hand, drought
in very wet areas may slow rapid streams and create pools
of stagnant water (45).
Global warming may also bring famine and drought,
leaving populations more susceptible to disease. Early
models to predict malaria rates in the 1920s were based on
rainfall and prices of wheat (50). When food was scarce,
the price of wheat increased, making price a surrogate for
crop failure and malnutrition.
Finally, unforeseen factors may also influence malaria.
The availability of an effective vaccine, better insecticides,
or more effective antimalarials would each reduce the preva-
lence of the disease. Breakdowns in existing public health
measures would increase cases of malaria. The balance be-
tween these factors may be more important than global cli-
mate (52).
Dengue is an important mosquito-borne disease affecting
humans and is transmitted by Aedes aegypti. This mosquito
is well adapted to the urban environment and successfully
breeds in containers where water is allowed to accumulate,
such as discarded cans, bottles, plastic containers and tires.
Aedes mosquitoes thrive in warmer environments but not
in dry environments. Thus, the effect of global warming
on diseases like dengue depends on both precipitation and
temperature (53,54). Vezzani et al. (55) studied the breeding
of Aedes mosquitoes in Buenos Aires, Argentina. They noted
highest abundances in breeding after several months with
mean temperatures above 20⬚C and accumulated rainfalls
above 150 mm. A sharp decline in egg laying was observed
when monthly mean temperature declined to 16.5⬚C, and no
eggs were found below 14.8⬚C. As with malaria, changes
in the incidence of dengue appear strongly related to non-
climatological factors. For example, there is a dramatic dif-
ference in the incidence of dengue along the Mexican⫺U.S.
border. States south of the border have a 500-fold increased
incidence of disease compared with those just north of the
border (48). Thus, climate appears to be only one factor in
transmission of the disease.
West Nile fever is another emerging viral infectious dis-
ease and is transmitted by Culex mosquito species. Its habitat
is usually near swamps, ponds and other bodies of stag-
nant water, waterways, parks, golf courses, undeveloped
 Global Warming
wood lots, and temporary wetlands in densely populated resi-
dential areas (56). Although the life span of the mosquito
diminishes with excessive temperatures, viral maturation
rates increase with temperature. It has been suggested that,
as a result of climate change, there could be a northward
shift in western equine and St. Louis encephalitis, with the
disappearance of the former in southern endemic regions
(57).
Other vectors will be affected to different extents. Models
to predict tick populations have also shown that arid condi-
tions decrease tick populations. However, epidemics of tick-
borne diseases such as Lyme disease have not been associ-
ated with climate change (58). As stated above, it is possible
that global warming will bring stronger or more frequent El
Niño events. This will be to the advantage of some vectors.
In the strong El Niño of 1997–1998, there was an associated
increase in Rift Valley Fever (51). The mosquito vector
populations increase during times of flooding, because more
eggs are immersed in water (59).
Vectors may transmit pathogens to non-human mamma-
lian hosts. Indeed, for some diseases humans are an acciden-
tal host. Arboviral encephalitides, such as West Nile
encephalitis, St. Louis encephalitis, and LaCrosse encephali-
tis, infect both human and non-human mammalian hosts
(54). Other pathogens, such as Borrelia burgdorferi, the
cause of Lyme disease, also utilize non-human mammalian
hosts. Clearly, the effect of climate on the non-human host
will affect human disease.
Rodent breeding increases during mild weather and de-
creases in times of drought or heat. However, drought may
drive rodents to seek indoor sources of water. This increases
the chances that humans will come in contact with rodents
and the insects that feed on rodents, such as lice. Transmission
of plague and similar diseases may increase with rodent
populations. Moreover, the hantaviruses are spread through
secretions or excretions of infected rodents.
In summary, vector-borne diseases will be affected by
global climate change. Malaria is likely to spread locally, es-
pecially into altitudes that are adjacent to current endemic
areas. However, for malaria to spread more widely in devel-
oped countries, it will be necessary for there to be a break-
down in public health measures that currently keep the
disease at bay. Other arthropod-borne diseases are likely to
fare similarly. Extreme climate change is not good for
humans or vectors, and it is difficult to predict the results.
Milder or more gradual climate change would allow both
humans and vectors to adapt. Successful adaptation in
humans might mean better vector control measures, more
effective therapies, vaccines, or public health measures.
Discussion
Human infections are intricately linked to the global envi-
ronment. By altering this environment, global warming
695
has significant potential to intensify selected infectious dis-
eases. Climatic effects are predicted to include crowding,
famine, water contamination, human migration, and alter-
ations in vector ecology, all of which increase infectious
diseases. We have dealt with these problems in the past with
varying success. Global warming will also cause economic
strain that may divert public health resources from existing
infections. Through planning and research, we can mitigate
the health effects of global warming. Through policy, poli-
tics, and global cooperation, we may reduce the environmen-
tal problems that cause global warming.
References
1. Titus JG. Strategies for adapting to the greenhouse effect. J Am Planning
Assoc 1990 (yosemite.epa.gov)
2. J. B. J. Fourier, Mém. de l’Ac. R. d. Sci. de l’Inst. de France, t. vii (1827).
3. Greenhouse Gases and Global Warming Potential Values—Excerpt
from the Inventory of U.S. Greenhouse Gas Emissions and Sinks:
1999–2000. Environmental Protection Agency, Office of Atmospheric
Programs, April 2002.
4. Intergovernmental Panel on Climate Change (IPCC). Houghton JT,
ed. Climate Change 1995: The Science of Climate Change. Cambridge,
UK: Cambridge University Press;1996.
5. Spencer RW, Christy JR. Precise monitoring of global temperature
trends from satellites. Science 1990;247:1558–1562.
6. Easterling DR, Horton B, Jones PD, Peterson TC, Karl TR, Parker DE,
Salinger MJ, Razuvayev V, Plummer N, Jamason P, Folland CK.
Maximum and minimum temperature trends for the globe. Science
1997;277:364–367.
7. Jones PD, Groisman PY, Coughlan M, Plummer N, Wang WC, Karl TR.
Assessment of urbanization effects in time series of surface air tempera-
ture over land. Nature 1990;347:169–172.
8. Groisman PY, Easterling DR. Variability and trends of total precipita-
tion and snowfall over the United States and Canada. J Clim 1994;7:
184–205.
9. Climate. Environmental Protection Agency. (yosemite.epa.gov/oar/
globalwarming.nsf/content/Climate.html)
10. Zavaleta ES, Shaw MR, Chiariello NR, Mooney HA, Field CB. Addi-
tive effects of simulated climate changes, elevated CO2, and nitrogen
deposition on grassland diversity. Proc Natl Acad Sci USA 2003;100:
7650–7654.
11. Goodland R. The concept of environmental sustainability. Am Rev
Ecol Syst 1995;26:1–24.
12. Human Health. In: The Regional Impacts of Climate Change: An
Assessment of Vulnerability. A Special Report of IPCC Working Group
II. Published for the Intergovernmental Panel on Climate Change.
November 1997.
13. Summary For Policymakers, The Regional Impacts Of Climate Change:
An Assessment Of Vulnerability, A Special Report of Working Group
II of the Intergovernmental Panel on Climate Change, Environmental
Protection Agency. 2001.
14. Gadgil A. Drinking water in developing countries. Annu Rev Energy
Environ 1998;23:253–286.
15. Cairncross S. Sanitation in the developing world: current status and
future solutions. Int J Environ Health Res 2003;13:S123–S131.
16. Thapar N, Sanderson IR. Diarrhoea in children: an interface between
developing and developed countries. Lancet 2004;363:641–653.
17. Gundry S, Wright J, Conroy R. A systematic review of the health
outcomes related to household water quality in developing countries.
J Water Health 2004;2:1–13.
696 Khasnis and Nettleman / Archives of Medical Research 36 (2005) 689–696
18. Esrey SA, Potash JB, Roberts L, Shiff C. Effects of improved water
supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hook-
worm infection, schistosomiasis, and trachoma. Bull WHO 1991;69:
609–621.
19. Haddad L, Martorell R. Feeding the world in the coming decades
requires improvements in investment, technology and institutions.
J Nutr 2002;132:3435S–3436S.
20. Matson PA, Parton WJ, Power AG, Swift MJ. Agricultural intensifica-
tion and ecosystem properties. Science 1997;277:504–509.
21. Tan G, Shibasaki R. Global estimation of crop productivity and the
impacts of global warming by GIS and EPIC integration. Ecol Model-
ling 2003;168:357–370.
22. Singh B, El Maayar M, André P, Bryant CR, Thouez J-P. Impacts of
a GHG-induced climate change on crop yields: effects of acceleration
in maturation, moisture stress and optimal temperature. Clima Change
1998;38:51–86.
23. Parry ML, Rosenzweig C. Food supply and the risk of hunger.
Lancet 1993;342:1345–1347.
24. Walker B, Steffen W, eds. The Terrestrial Biosphere and Global Change:
Implications for Natural and Managed Ecosystems. Stockholm: Interna-
tional Geosphere Biosphere Program;1997.
25. Environmental Data Services. The unfinished climate business after
Kyoto. ENDS Rep 1997;275:16–20.
26. United Nations. World urbanization prospects, 1990. New York:
United Nations;1991.
27. Wilson ME. Travel and the emergence of infectious diseases. Emerg
Infect Dis 1995;1:39–46.
28. Morse SS. Factors in the emergence of infectious diseases. Emerg Infect
Dis 1995;1:7–15.
29. Rogers DJ, Randolph SE, Snow RW, Hay SI. Satellite imagery in the
study and forecast of malaria. Nature 2002;415:710–715.
30. Reiter P. From Shakespeare to Defoe: malaria in England in the Little
Ice Age. Emerg Infect Dis 2000;6:1–11.
31. Nchinda T. Malaria: a reemerging disease in Africa. Emerg Infect
Dis 1998;4:398–403.
32. Barat LM, Palmer N, Basu S, Worrall E, Hanson K, Mills A. Do
malaria control interventions reach the poor? A view through the equity
lens. Am J Trop Med Hyg 2004;7:174–178.
33. Tanser FC, Sharp B, le Sueur D. Potential effect of climate change on
malaria transmission in Africa. Lancet 2003;362:1792–1798.
34. Greenwood B, Mutabingwa T. Malaria in 2002. Nature 2002;415:
670–672.
35. Newman RD, Parise ME, Barber AM, Steketee RW. Malaria-related
deaths among U.S. travelers, 1963–2001. Ann Intern Med 2004;141:
547–555.
36. Hanson K. Public and private roles in malaria control: the contributions
of economic analysis. Am J Trop Med Hyg 2004;71(2 Suppl):168–173.
37. White NJ. Malaria. In: Cook G, ed. Manson’s Tropical Diseases.
London: W.B. Saunders;1996. pp. 1087–1164.
38. Matsuno Y, Konradsen F, Tasumi M, Hoek WVD, Amerasinghe FP,
Amerasinghe PH. Control of malaria mosquito breeding through irriga-
tion water management. Int J Water Resources Dev 1999;15:93–105.
39. Mutero CM, Blank H, Konradsen F, van der Hoek W. Water manage-
ment for controlling the breeding of Anopheles mosquitoes in rice irri-
gation schemes in Kenya. Acta Trop 2000;76:253–263.
40. Bayoh MN, Lindsay SW. Effect of temperature on the development
of the aquatic stages of Anopheles gambiae sensu stricto (Diptera:
Culicidae). Bull Entomol Res 2003;93:375–381.
41. Pålsson K, Jaenson TGT, Dias F, Laugen AT, Björkman A. Endophilic
Anopheles mosquitoes in Guinea Bissau, West Africa, in relation to
human housing conditions. J Med Entomol 2004;41:746–752.
42. el-Akad AS. Effect of larval breeding conditions on the morphological,
ovarian and behavioral characteristics of Anopheles pharoensis of the
emerged females. J Egypt Soc Parasitol 1991;21:459–465.
43. Gubler DJ. Resurgent vector-borne diseases as a global health prob-
lem. Emerg Infect Dis 1998;4:442–450.
44. Patz JA, Khaliq M. MSJAMA: global climate change and health:
challenges for future practitioners. JAMA 2002;287:2283–2284.
45. Kovats RS, Bouma MJ, Hajat S, Worrall E, Haines A. El Nino and
health. Lancet 2003;362:1481–1489.
46. Haines A, Patz JA. Health effects of climate change. JAMA 2004;291:
99–103.
47. Poveda G, Rojas W, Quinones ML, Velez ID, Mantilla RI, Ruiz D,
Zuluaga JS, Rua GL. Coupling between annual and ENSO timescales
in the malaria-climate association in Colombia. Environ Health Per-
spect 2001;109:489–493.
48. McCarthy M. Uncertain impact of global warming on disease.
Lancet 2001;357:1183.
49. Patz JA, Kovats RS. Hotspots in climate change and human health.
BMJ 2002;325:1094–1098.
50. Hay SI, Cox J, Rogers DJ, Randolph SE, Stern DI, Shanks GD,
Myers MF, Snow RW. Climate change and the resurgence of malaria
in the East African highlands. Nature 2002;415:905–909.
51. Linthicum KJ, Anyamba A, Tucker CJ, Kelley PW, Myers MF, Peters
CJ. Climate and satellite indicators to forecast Rift Valley fever
epidemics in Kenya. Science 1999;285:397–400.
52. Worrall E, Rietveld A, Delacollette C. The burden of malaria epidemics
and cost-effectiveness of interventions in epidemic situations in Africa.
Am J Trop Med Hyg 2004;71(Suppl 2):136–140.
53. Alto BW, Juliano SA. Precipitation and temperature effects on popula-
tions of Aedes albopictus (Diptera: Culicidae): implications for range
expansion. J Med Entomol 2001;38:646–656.
54. Gubler DJ, Reiter P, Ebi KL, Yap W, Nasci R, Patz JA. Climate
variability and change in the United States: potential impacts on
vector- and rodent-borne diseases. Environ Health Perspect 2001;
109(Suppl 2):223–233.
55. Vezzani D, Velazquez SM, Schweigmann N. Seasonal pattern of abun-
dance of Aedes aegypti (Diptera: Culicidae) in Buenos Aires City,
Argentina. Mem Inst Oswaldo Cruz 2004;99:351–356.
56. Andreadis TG, Anderson JF, Vossbrinck CR. Mosquito surveillance
for West Nile Virus in Connecticut, 2000: isolation from Culex pipiens,
Cx. restuans, Cx. salinarius, and Culiseta melanura. Emerg Infect
Dis 2001;7:670–674.
57. Reeves WC, Hardy JL, Reisen WK, Milby MM. The potential effect
of global warming on mosquito-borne arboviruses. J Med Entomol
1994;31:323–332.
58. Randolph SE. Evidence that climate change has caused emergence of
tick-borne diseases in Europe. Int J Microbiol 2004;293(Suppl 3)7:5–15
59. Patz JA. A human disease indicator for the effects of recent global
climate change. Proc Natl Acad Sci USA 2002;99:12506–12508.